Chronic and Recurrent Otitis Media (Ear Infections)
A normal (left) ear drum and an ear with acute otitis media (right). Note the thin clear tympanic membrane (ear drum) on the left. The ear with acute otitis media has a bulging tympanic membrane (due to pus in the middle ear) and increased redness over portions of the drum.
Anatomic Drawing of the ear. Otitis media occurs in the middle ear.
What is otitis media? Otitis media means inflammation of the middle ear (the space behind the ear drum). Many different conditions are lumped together under the term otitis media - including infections due to a number of different viruses or bacteria, or the presence of different types of uninfected fluid. The presence of middle ear fluid and redness or inflammation of the ear drum is usually referred to as acute otitis media, is typically due to bacterial infection, and is usually treated with antibiotics. Chronic otitis media means long-standing middle ear fluid (with or without infection). Fluid in the ear, without signs of infection or inflammation, is usually called otitis media with effusion or serous otitis media.
Aren't all these antibiotics bad? Yes...and no. The major concern these days is antibiotic resistance - a problem that is clearly worsened by community usage of antibiotics. If a child has been on several antibiotics, and is still having ear or sinus infections, the bacteria are most likely resistant to many or most commonly prescribed antibiotics. The patient does not really "become immune to the antibiotics", rather the bacteria are more tolerant. Antibiotics (especially those containing amoxicillin) are still recommended for most ear infections because... if the infections are untreated, a small percentage (perhaps 1/400 patients) will have a severe or life-threatening complication of the untreated infection, and many more patients will have prolongation of symptoms. Of course, some patients are very poorly tolerant of antibiotics, with gastrointestinal side-effects or rashes.
Is all this due to allergy? Many families reach the conclusion that allergies play a major role in their child's ear or nose/sinus problems. While the answer to this is controversial, we feel that the evidence for this is very weak. The symptoms (especially nasal drainage) looks like it may be allergic, but biochemical and immunologic analyses usually suggests infectious causes (viruses and bacteria) as opposed to allergy...especially in the child less than 3 years of age. The role of inhalant allergies in precipitating ear infections, we feel, has NOT been supported by sound studies...and the role of "food allergies" is even more difficult. Obviously, there are occasional exceptions. More obviously, the biggest proponents of an allergic cause are those individuals and groups who make their living off of allergy diagnosis or therapy.
What about resistance to antibiotics? This is one of the major challenges facing those of us treating otitis media. Interestingly, the problem is not as visible to many families and clinicians as it might be because most of the infections (unfortunately, not all) improve regardless of whether antibiotics are used and whether antibiotics really work well or not. Therefore, several companies are still able to sell hundreds of millions of dollars of antibiotics that are not very effective in killing the bacteria about which we are concerned.
The major risk factors that increase the chance that a child is infected with a drug-resistant strain of bacteria include young age (less than 2), prior antibiotic consumption (the more, the worse), exposure to other children (especially in daycare), and the winter months (when more antibiotics are prescribed). Most of the problem resistance is seen in the two bacteria: Streptococcus pneumoniae (also known as "pneumococcus") or Hemophilus influenzae. Antibiotics that seem to be having problems killing either organism include sulfa drugs, azithromycin (Zithromax), clarithromycin (Biaxin), cefaclor (CeClor) and loracarbef (Lorabid). Hemophilus failures are relatively common with cefprozil (Cefzil). Pneumococcal failures are most likely with ceftibuten (Cedax) and cefixime (Suprax). Among the more active agents against these two bacteria are amoxicillin-clavulanate (Augmentin), cefuroxime axetil (Ceftin) and cefpodoxime proxetil (Vantin), and the injectable drug ceftriaxone (Rocephin). Still, these may fail against some strains of bacteria...and they generally have more gastro-intestinal side effects than some of the "weaker" choices. The bottom line: There are no perfect antibiotic choices for otitis media, but some are more effective than others.
Amoxicillin is still considered the most appropriate initial choice, even though it does not work in all cases. The pneumococcus, which can be a very dangerous bacteria, remains relatively more susceptible to amoxicillin than most of the other choices; and amoxicillin has a long record of safety. Recently, we have recommended that it be prescribed in higher doses...in an effort to combat some of the resistance. Other combinations of antibiotics may prove to be somewhat more effective that a single choice.
Finally, many parents feel like antibiotics aren't working when the child suffers several different infections within a short time. This may not reflect a treatment failure at all; just a new infection...often as a result of increased exposure to other children and the viral infections that set the child up for an ear infection.
When will my child outgrow the problem? The majority of children with otitis media outgrow the problem sometime between two and three years old. Well over 90% improve by school age. Only a very small percent of children continue to have problems into adolescence. The presence of other problems...such a a history of cleft palate or adenoid disease may prolong middle ear disease.
What role do the tonsils and adenoids play - aren't they important? In general, tonsillar problems do not affect the health of the middle ear, and do not cause otitis media. An occasional case of markedly enlarged tonsils may cause enough problems to affect the presence or clearance of middle ear disease. The adenoids act somewhat like a sponge in the back of the nose, and appear to be a reservoir for the bacteria that might cause ear infections. Additionally, some cases of adenoidal enlargement seem to be related to middle ear disease. Therefore, selected cases of otitis media may be significantly improved with adenoid removal (adenoidectomy). Adenoidectomy is commonly recommended in children who continue to have ear problems after one or two sets of tympanostomy tubes have extruded. We will also often recommend adenoidectomy in young children with unrelenting otitis media who have signs of posterior nasal obstruction (presumably due to enlarged adenoids) or who have frequent or chronic rhinorrhea (nasal discharge).
Is otitis media easy to diagnose? Otitis media can be very easy...or very difficult... to diagnose - depending on the patient. The diagnosis of acute otitis media requires the presence of fluid and the presence of redness or inflammation of the ear drum. Otitis media with effusion (also known as ear fluid) has fluid but no inflammation. Small ear canals and ear drums (such as in infants or Down syndrome children) make the diagnosis more difficult ...as does the presence of ear wax or other debris. Crying will cause the face and ear drums to turn red and make the diagnosis even more difficult. Irritability of the child, poor sleeping, or rubbing the ears does NOT necessarily mean that there are significant ear problems...or infections in need of antibiotics. Parents might appropriately be concerned about the accuracy of the diagnosis if their clinician is having difficulty visualizing the ear drum...because of small size, poor cooperation, or ear wax. Some cases of ear fluid are difficult to diagnosis because the fluid behind the ear drum is very similar to the color of the drum itself.
Can we tell for sure what the germs are? Usually not. The only definitive way is to culture the material behind the ear drum (a procedure call tympanocentesis)...which requires making a hole in the ear drum with a needle, small knife, or a laser. Because of the discomfort, this is recommended only in selected cases. However, the recent problems with antibiotic resistance and subsequent persistent infections has resulted in an increased frequency of recommendations for such cultures. Since the bacteria usually come from the nasal cavity, cultures of the back of the nose (nasopharynx) are somewhat, but not completely, predictive.
Why does my child have so many problems? Two reasons are commonly cited as the cause for infants and children having more problems than older children or adults. First, their immune system does not fight the viral and bacterial infections of the respiratory (or gastrointestinal) tract as effectively. This usually improves to close to adult capability by four years of age. Second, the structure of the eustachian tube, in young children, is felt to make fluid and infections more likely...due to a straighter angle and a shorter length. Some experts suggest that perhaps 70% of the ear problems in the US are related to exposure to other children...as in daycare. Many, but not all, children will have a marked reduction in ear and nasal infections when placed in a care situation with few children (less than 3-7). An occasional child will have severe immune deficiency problems...although most of these children have severe problems with infections at other sites. For a discussion of the role of allergies, see above.
What about hearing loss? All children with middle ear infection or fluid have some degree of hearing loss. The average hearing loss in ears with fluid is 24 decibels...roughly equivalent to wearing ear plugs and about the level of the very softest of whispers. Thicker fluid can be associated with much more loss...up to 45 decibels (the range of conversational speech). Misunderstanding speech is a more common problem that not hearing it at all. The most commonly cited adverse effect of such hearing loss is said to be the possibility of delayed speech and language skills...a problem that is generally reversible by correcting the problem. There may be a permanent loss of an ability to consistently understand speech in a noisy environment (such as a classroom) when a child has long-standing hearing loss due to ear fluid or other causes - thought to reflect incomplete development of the brain cortex pathways that assist in such function. Draining the fluid (as with ear tubes) immediately restores the hearing.
Tell me all about tympanostomy tubes...There are many different tube types...with various sizes, designs, composition, and color. The smaller tubes generally stay in a shorter period of time (6 months). Some tubes with large inner flanges stay in a long period of time (2-3 years) and are associated with a higher rate of perforation after tube extrusion. Tubes are usually placed during a light, brief general anesthesia...a procedure that typically takes the surgeon 5-10 minutes to complete. As the ear grows, the tubes usually extrude spontaneously. For most patients, we place tubes that last an average duration of 10 months. For a more comprehensive discussion about tubes, click here.